EP3821844A1 - Verfahren und system zur bestimmung einer optimalen position eines chirurgischen instruments in bezug auf einen knochenverfolger eines patienten - Google Patents

Verfahren und system zur bestimmung einer optimalen position eines chirurgischen instruments in bezug auf einen knochenverfolger eines patienten Download PDF

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Publication number
EP3821844A1
EP3821844A1 EP19306464.9A EP19306464A EP3821844A1 EP 3821844 A1 EP3821844 A1 EP 3821844A1 EP 19306464 A EP19306464 A EP 19306464A EP 3821844 A1 EP3821844 A1 EP 3821844A1
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EP
European Patent Office
Prior art keywords
bone
patient
image
interest
preoperative
Prior art date
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Pending
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EP19306464.9A
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English (en)
French (fr)
Inventor
Stéphane Lavallee
David ARMAND
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Ecential Robotics SAS
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Surgivisio
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Priority to EP19306464.9A priority Critical patent/EP3821844A1/de
Priority to PCT/EP2020/081869 priority patent/WO2021094431A1/en
Priority to US17/770,687 priority patent/US20220370152A1/en
Publication of EP3821844A1 publication Critical patent/EP3821844A1/de
Pending legal-status Critical Current

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    • G06T2207/30008—Bone

Definitions

  • the invention relates to a method and a system for determining an optimal position of a surgical instrument relative to a patient's bone tracker. Said method can in particular be used for navigating a tool and/or an implant in a 3D image during the surgical intervention.
  • the method for performing the surgical procedure may be as follows.
  • a 3D image of the bone is acquired preoperatively, for example using a CT scan.
  • the patient is typically in a lying position.
  • Said preoperative 3D image is used to plan the surgical intervention.
  • intraoperative 2D X-ray images of the bone can be acquired for that purpose.
  • the 2D X-ray images can be registered with the 3D preoperative image in view of navigating the tool and/or implant on the 2D X-ray images (fluoronavigation).
  • the 2D and 3D images of the bone are acquired when the patient is lying on the operating table.
  • the result may not be optimal for the patient in standing position.
  • Document EP 3 398 551 relates to a method for preoperatively planning a total ankle replacement that intends to take the standing position of the patient into account.
  • 2D X-ray images of the patient's leg are acquired while the patient is in standing position, and a 3D CT image of the patient's leg is acquired while the patient is in supine position.
  • the 3D CT image is segmented to generate 3D models of the patient's bones.
  • These 3D models are then registered on the 2D preoperative images, so as to represent the models in the standing position of the patient.
  • the planning may thus be done on said reoriented models.
  • this method is carried out preoperatively.
  • the surgeon has to register the preoperative planning performed on hybrid 3D CT and 2D x-ray images with an intra-operative patient position located by a navigation system.
  • Said registration may be made by various techniques (e.g. palpation of a number of points on the bone surface, acquisition of an intraoperative 2D or 3D image and registration of the preoperative planning onto said intraoperative image).
  • said registration involves at least one additional step in the surgical procedure.
  • Magnetic resonance imaging does not expose the patient to such an irradiation, but the acquisition of a 3D image takes a much longer time than a CT scan, and it is also very expensive and not always accurate in three dimensions.
  • a goal of the invention is to provide a method for determining an optimal position of a surgical instrument relative to at least one patient's bone tracker taking into account a position of interest of the patient that overcomes the above drawbacks.
  • a goal of the invention is to minimize the number of steps to carry out the surgical procedure and to minimize the exposure of the patient to X-rays.
  • a goal of the invention is to obtain a planning of the surgical procedure that takes into account a position of interest of the patient, without using CT scans, whether preoperatively or intraoperatively.
  • a first embodiment relates to a method for determining an optimal position of a surgical instrument relative to a patient's bone tracker, comprising the following steps:
  • a second embodiment relates to a method for determining an optimal position of a surgical instrument relative to at least two patient's bone trackers, comprising the following steps:
  • a localization device which locates positions and orientations of trackers that can be attached to bones, surgical instruments, sensors or any other device.
  • Such localization devices may use various technologies, including optical, magnetic, inertial, ultrasonic systems.
  • a bone tracker means a device configured to be rigidly connected to a patient's bone.
  • rigid connection is meant a connection that is not deformable beyond the accuracy required to localize the tracker for the intended surgical application.
  • a rigid connection may be an attachment of the tracker directly to the bone, or to a body part in the vicinity of the bone which is relatively stable with the desired accuracy.
  • Such a bone tracker comprises at least a base configured for the rigid attachment to the patient's bone and at least one element detectable by the localization device.
  • the tracker may comprise different elements, that may be reproducibly detachable.
  • the term "intraoperative” designates a step that is implemented in the operative room, when the patient has been equipped with the bone tracker(s). It is to be noted that the step of attachment of the bone tracker(s) is to be considered as a preliminary step and is excluded from the present invention.
  • a surgical instrument may be a surgical tool (e.g. a burr, a saw, a reamer, a drill%) or an implant (e.g. a hip prosthesis, a pedicular screw, a vertebra cage, a disc prosthesis).
  • the surgical instrument is equipped with a tracker to be localized with respect to the bone tracker.
  • the surgical instrument may be replaced by a bone tracker itself.
  • the surgical instruments can be navigated manually or guided by passive, haptic or active robotic devices.
  • equipped is meant in the present text that the tracker is attached directly to the instrument or to another device coupled to the instrument (e.g. an instrument holder, or a device operating the instrument such as a robot), in such a way that the instrument can be localized using said tracker.
  • the method according to the invention benefits from CBCT imaging (Cone Beam Computed Tomography), which is an imaging technique commonly used intraoperatively, in particular with imaging devices having an open C architecture, well known as C-arm. Said technique provides a smaller exposure of the patient to X-rays. Although the quality of a CBCT image is usually lower than the one of a CT image, this is not detrimental to the method since the method does not require any segmentation of the patient's bone(s).
  • CBCT imaging Cone Beam Computed Tomography
  • O-armTM Medtronic
  • Artis ZeegoTM Siemens
  • CIOSTM Zero-Valuemens
  • Loop-XTM Brainlab
  • Vario3DTM Vario3DTM
  • the method according to the invention is also advantageous in that the planning, which is done intraoperatively, can be directly applied to carry out the surgical procedure.
  • the planning is done in a coordinate system attached to the bone tracker.
  • the global time and number of steps are reduced as compared to a surgical procedure using a planning as described in document EP 3 398 551 .
  • the position of interest is a standing position of the patient.
  • the operative position is a lying position of the patient.
  • the at least one preoperative 2D X-ray image received in step (a) is geometrically calibrated.
  • At least two 2D X-ray images are received in step (a) and said images are geometrically calibrated and registered with each other.
  • step (d) comprises a step of importing a preoperative planning based on the at least one preoperative 2D X-ray image received in step (a).
  • the method comprises acquiring at least two intraoperative 2D X-ray images on which at least one anatomical landmark of the patient is visible and determining a position of said anatomical landmark of the patient from said intraoperative 2D X-ray images.
  • the method may further include navigating a tool and/or an implant on the registered 3D image.
  • the method may further include using a robot to position a tool and/or prepare the bone to receive an implant.
  • step (e) uses a preoperative planning based on the at least one preoperative 2D X-ray image acquired in step (a).
  • Another object of the invention is a system for implementing the method described above.
  • FIG. 1 represents a surgical system configured for carrying out the invention.
  • the system comprises an operating table 1 onto which the patient may lie, e.g. in prone, supine or lateral position.
  • the system comprises a localization device 2.
  • the patient is equipped with at least one bone tracker 3 which may be localized in real time by the localization device.
  • the system further comprises a CBCT imaging system in the form of a C-arm 4.
  • the imaging system comprises at least one X-ray source and at least one X-ray 2D detector.
  • the imaging system is configured to rotate and/or translate relative to the operating table in order to acquire intraoperative 2D and/or 3D images of the patient.
  • the imaging system may be motorized on at least one movement which contributes to generate a 3D acquisition trajectory, i.e. each movement of the system according to a degree of freedom is generated by a respective motor.
  • Each motor is associated to an encoder allowing knowing, at any time, the relative position of the imaging system with respect to a reference position.
  • When a 2D image is acquired, the corresponding position of the imaging system is recorded.
  • each 2D image is recorded in the referential of the imaging system.
  • the imaging system allows constructing a 3D image from a set of 2D images may be used for reconstruction of a 3D image.
  • the system further comprises at least one computer (not shown) configured to receive images from the C-arm and localization data from the localization device and to implement the algorithms described below to perform the method according to the invention.
  • the system may further comprise a display monitor coupled to the computer and configured to display the registered 3D image along with the planning.
  • the bone tracker comprises a base allowing rigid fixation to a patient's bone.
  • the fixation may be either direct (e.g. using at least one percutaneous pin, needle, broach or screw implanted into the bone in a minimally invasive way) or indirect (i.e. using attachment means external to the bone, such as an adhesive tape on the skin close to the bone, straps, etc. to immobilize the base with respect to the bone without passing through the patient's skin).
  • a deformable material may be interposed between the base and the skin.
  • Said deformable material can be silicon, thermosetting foam, a bag containing microbeads that can be rigidified under vacuum, or an adhesive tape.
  • the material fitting to the body part shape provides some stability to the base relative to the bone, especially in non-flat regions.
  • Adhesion between the material and the skin and the base can be obtained either by adhesive properties of the material or by external means such as straps, adhesive tape surrounding the base.
  • the indirect fixation is particularly adapted when there is only a small thickness of soft tissues between the bone and the base, since this situation is considered to provide sufficient rigidity to prevent any movement of the base relative to the bone.
  • indirect fixation can be used when the bone pertains to a patient's finger, wrist, foot, etc. Such an indirect fixation has the advantage of being non-invasive.
  • direct and indirect fixation can be combined.
  • the base may be linked to the skin via a deformable material that fits to the body part shape and at least one percutaneous pin, broach, needle or screw further secures the base to the bone.
  • a deformable material that can become rigid is first used to fix the individual bones or bone fragments together: conventional plaster, thermo-deformable material, poach of micro spheres with vacuum, etc. and the base is then fixed to this deformable material once it is rigid.
  • the base advantageously has generally a height of less than 20 mm. In this way, the base is very compact and protrudes only to a limited extent from the patient's skin. Thus, it is quite unlikely that the medical staff unintentionally hits the base and thus displaces it relative to the bone during the surgical intervention.
  • the tracker further comprises at least one localization element rigidly coupled thereto.
  • Said coupling can be permanent (the localization element being integral with the base or irreversibly fixed to the base) or temporary (the localization element being detachable from the base).
  • the localization element can be detached from the base when no tracking is required, thus offering a temporary coupling. This reduces the risk of having the localization element hit by the medical staff and thus causing a displacement of the base relative to the bone. It also saves operating space when the tracker is not needed.
  • the base and localization element have cooperating fixation means that allow detaching and attaching the localization element in a reproducible way (i.e. always in a same known position and orientation relative to the base).
  • the tracker is an optical tracker (either active or passive).
  • the localization element comprises a plurality of reflective balls having a known relative position.
  • the tracker is an electromagnetic tracker, the localization element being an electromagnetic sensor.
  • An electromagnetic tracker has the advantage of being more compact than an optical tracker.
  • the localization element may be removable or not from the base.
  • the localization element may be embedded in a support which can be attached to the base with reproducible fixation means.
  • the localization element may be lodged in a recess of the base and thus does not protrude from the base.
  • the electromagnetic tracker contains inertial sensors that can be used to detect the presence of artefacts.
  • the invention is not limited to a specific tracking technology and the skilled person can adapt the described embodiments to the selected technology.
  • a tracker is usually attached to each bone of interest. But it is also possible to extrapolate or interpolate the positions of trackers between non-adjacent bones.
  • a registration phantom may also be rigidly attached to the tracker base.
  • the registration phantom is made of a radiotransparent material and comprises a plurality of radiopaque fiducials having a known shape and size (e.g. balls or pins) arranged in a known position.
  • the radiopaque fiducials are visible in the 2D image. Since the shape, size and arrangement of the radiopaque fiducials is known, the image can be determined in the referential of the calibration phantom and the 3D reconstruction can be carried out based on the position of the radiopaque fiducials in each 2D image. It is also possible to perform a 3D image reconstruction directly without using the fiducials and then to detect the fiducials directly in the reconstructed 3D image.
  • the registration phantom Since the registration phantom is not required during the whole surgical intervention but only at specific times when registration of the images acquired by the imaging system has to be carried out, the registration phantom is detachable from the base.
  • the base and the registration phantom have cooperating fixation means that allow attaching the registration phantom in a reproducible way (i.e. always in a same known position and orientation relative to the base). This allows saving operating space when the phantom is not needed.
  • the registration phantom may have any shape and size suitable for the intended application.
  • the registration phantom since the registration phantom is only attached to the base when it is required for image registration, the registration phantom can have a greater size than the base. In this way, it is possible to have the radiopaque balls located at a greater distance from each other and thus improve the accuracy of the registration.
  • the registration phantom and, if applicable, the localization element is maintained onto the base using magnetic force thanks to a magnet arranged in the base.
  • This magnetic fixation has also the advantage of being detached automatically if a certain level of force is exerted on the part mounted to the base, which avoids damaging or displacing the relative position and fixation of the base with respect to the bone.
  • FIG. 2 illustrates a preferred embodiment of such a device in the case of optical tracking technology.
  • the base 50 may be attached to the bone B by a percutaneous pin 60.
  • the base may be in contact with the patient's skin S or may be maintained at a certain distance from the skin.
  • the base comprises a reproducible fixation 52 for both the registration phantom 70 and the localization element 30. In this way, the design of the base is as simple as possible and no space is lost by providing two distinct fixations areas on the base.
  • the localization element 30 comprises an interface 31 with the base provided with a fixation 32 cooperating with the fixation 52 of the base.
  • the registration phantom 70 comprises a plurality of radiopaque fiducials 71 and a fixation 72 cooperating with the fixation 52 of the base. When assembled, the base 50 and localization element 30 together form a bone tracker.
  • the surgical intervention is intended to operate at least one patient's bone and/or to place an implant into said bone.
  • the intervention is carried out on a single bone or to a plurality of bones.
  • the bones may form a joint (e.g. hip or knee) or may belong to a more complex anatomical structure (e.g. spine).
  • the method according to the invention may be implemented in different manners depending on the application.
  • FIG. 3 schematically represents a preoperative image (left) and the intraoperative setting (right) for hip surgery.
  • the preoperative image is acquired with the patient in standing position, whereas during the surgical intervention the patient lies in supine position on the operating table 1, the femur and the pelvis being each equipped with a respective tracker 3f, 3p.
  • the relative positions of the pelvis P and femur F are thus different between the preoperative image and the intraoperative image acquired by the C-arm 4.
  • This registration which is represented by the arrows, generally involves bounding boxes BBfp, FFpp that define regions of interest in the preoperative image and/or bounding boxes BBfi, BBpi that define regions of interest in the intraoperative images.
  • FIG. 4 is a flow chart of the method according to an embodiment of the invention, which may be applicable in particular when a single bone is to be operated.
  • step 100 at least one preoperative 2D X-ray image is received.
  • Said at least one image may have been acquired in another place than the operative site, for example in a radiology centre.
  • the image may be transmitted to the surgical system by any suitable communication means, such as a PACS network.
  • the patient is in a position of interest, i.e. a position that has an impact on the configuration of the bone and on the interaction of the bone with other anatomical structures of the patient.
  • said position of interest may be a standing position. Indeed, in this position, the lower members of the patient bear the patient's weight and the relative position of the spine, pelvis, and bones of the lower members may be impacted by said weight and by the natural patient's posture.
  • Each image is geometrically calibrated, i.e. the features of the geometric projection of the imaged object onto the plane of the image are known.
  • only a frontal 2D X-ray image of the patient may be acquired.
  • both a frontal and a lateral 2D X-ray image may be acquired. Said images are then registered with each other, and the registered images are received by the surgical system.
  • said frontal and lateral images may be acquired simultaneously using two X-ray beams by an imaging system provided by EOS ImagingTM.
  • the patient is installed in the operating room, on the operating table, and equipped with a bone tracker.
  • the bone tracker may be attached directly to the bone, or to a body part rigidly connected to the bone, e.g. the patient's skin in particular if soft tissues extending between the skin and the bone are not too thick.
  • the bone tracker defines a coordinate system.
  • the bone tracker is made of several detachable elements, only a part of these elements (in particular, the base) may be attached to the patient at this stage.
  • Step 200 and the following steps belong to the intraoperative part of the method.
  • step 300 a 3D image is acquired by the CBCT imaging system.
  • the registration phantom is attached to the base using the reproducible fixation.
  • the motorized imaging system acquires a plurality of 2D X-ray images of the patient in the region of the bone.
  • a 3D reconstruction algorithm is implemented by the computer so as to generate a 3D image which is defined in the referential of the imaging system. 3D reconstruction is known per se and thus will not be described in detail here.
  • a registration algorithm is implemented by the computer so as to generate the 3D volume in the referential of the registration phantom, based on the known phantom dimensions that are stored in a memory of the computer or that may be downloaded from another system.
  • the 3D image may be registered to the coordinate system of the bone tracker.
  • Step 305 may be carried out before or after step 300.
  • Step 305 involves the acquisition of several 2D X-ray images, so that each anatomical landmark is visible in at least two of said images.
  • the Lewinnek plane is a reference plane of the pelvis, which is linked to the balance of the pelvis.
  • Said plane is defined as being the plane containing the left and right anterior superior iliac spine (ASIS) and the pubic symphysis.
  • ASIS anterior superior iliac spine
  • the coordinates of the Lewinnek plane in addition to the 2D frontal X-ray image, allow fully defining the orientation of the patient's pelvis in the standing position.
  • the intraoperative 3D medical image is registered onto the at least one preoperative 2D X-ray image, so as to obtain a registered 3D image representing the bone in the position of interest.
  • register 3D and 2D images there exist various techniques to register 3D and 2D images, and any of them may be used in the present invention.
  • Other well-known methods of 3D/2D registration use a maximization of a similarity score between the projections of the 3D volume and the 2D projection, using cross correlation coefficient, entropy, or mutual information for example.
  • these registration methods do not involve any segmentation of the images.
  • the registration may be initialized using a bounding box drawn on either the 3D or the 2D image, the bounding box including at least a part of the bone.
  • step 500 the surgical procedure is planned on the registered 3D image. Since the 3D image has been registered on the preoperative 2D X-ray image(s), the planning takes into account the position of interest. For example, hip surgery can be planned in a virtually standing patient, and in three dimensions.
  • the planning may have been done on the preoperative 2D X-ray images (step 101) and imported in the surgical system with the 2D X-ray images.
  • step 500 comprises registering the 3D image with said preoperative planning.
  • step 600 an optimal position of the surgical instrument to implement the planning defined in step 500 is determined.
  • the optimal orientation of a prosthesis cup in inclination and anteversion is determined in a coordinate system of a patient standing, with values of angles that are meaningful.
  • the planning of a deformity correction using screws and rods is performed for a standing reference position of the patient, and the relative desired positions and orientations can be defined vertebra per vertebra, once the 3D image area around each vertebra has been registered with the 2D X-ray image that include corrections. And the intra-operative correction of the whole spine can be compared in three dimensions with the planned correction. If only one lateral X-ray image is used preoperatively, the spine correction is planned in said lateral X-ray image, on the basis of a standing position, in order to restore a convenient balance of the spine that falls within known values and references, registration is then performed for each vertebra by matching the 3D local volume around a vertebra and its projection.
  • several vertebrae are equipped with trackers, and it is now possible to compare the real sagittal balance of the spine with the desired balance before the rods are fully fixed and to correct accordingly if necessary.
  • step 700 the surgical procedure is launched using a navigation device and/or a robotic device.
  • the registration phantom is no longer required.
  • the registration phantom may be detached from the base of the modular device and the localization element is attached to the base using the reproducible fixation to form the bone tracker.
  • the localization element is permanently attached to the base, the localization element is present during all the protocol, including the previous steps.
  • the computer implements an algorithm to register the above-mentioned 3D image with the coordinate system of the bone tracker.
  • a localization camera is installed in the vicinity of the patient such that the bone tracker is in the field of view of the camera.
  • a surgical instrument equipped with an instrument tracker is introduced in the operating field in order to carry out the surgical intervention.
  • the instrument tracker is also in the field of view of the localization camera, such that the position of the instrument is known at each time.
  • the user With a navigation device, the user is provided with the registered 3D image onto which the planning has been done.
  • the positions of the instrument tracker and bone tracker may be localized with respect to the registered 3D image.
  • the user may then use the displayed image and planning to position the surgical instrument in an optimal way.
  • the robot trajectory allowing implementing the planned procedure is computed and then executed.
  • FIG. 5 illustrates an embodiment of the 2D/3D registration step 400, which may be implemented in case at least two bones are to be operated during the surgical intervention.
  • each of said bones is equipped with a bone tracker.
  • the intraoperative 3D image is usually small, it may not include the whole set of bones. However, this is not detrimental to the method, provided that the 3D image includes at least the bone regions that are of interest for the surgical intervention.
  • said regions of interest may be the bone parts forming the joint (e.g. the acetabulum and the femoral head for a hip joint).
  • said regions of interest may be a few vertebrae that are equipped with a bone tracker. In the latter case, several intraoperative 3D images may be acquired and registered together to constitute a whole spine, with multiple trackers attached to several vertebrae.
  • the preoperative 2D X-ray images are usually of a size sufficient to include the whole set of bones.
  • the 2D/3D registration will thus be done only in the regions of interest.
  • step 400 may comprise the following substeps.
  • a bounding box is drawn on the preoperative 2D X-ray image(s) so as to encompass the region of interest.
  • a bounding box is drawn around the region of interest of each bone.
  • each vertebra equipped with a tracker forms a region of interest and a bounding box is drawn around each of said vertebrae.
  • the bounding box is an advantageous tool for initializing the registration.
  • the shape of the bounding box is not necessarily a parallelepiped and it is as close as possible to the shape of the region of interest, in order to improve the convergence and increase the accuracy and reliability of the registration.
  • the bounding box may be drawn manually by the user. Alternatively, the bounding box may be automatically drawn by the computer, and may be interactively adjusted by the user. However, such a bounding box does not involve any accurate segmentation of the bone.
  • each region of interest defined by a respective bounding box is registered with the corresponding region of the intraoperative 3D image.
  • step 403 an integrated 3D image is computed from the registered regions.
  • the registration may not be initialized based on the preoperative 2D X-ray image(s) as described above, but on the intraoperative 3D image(s).
  • a bounding box is drawn on the intraoperative 3D image(s) so as to encompass the regions of interest.
  • a bounding box is drawn around the region of interest of each bone.
  • each vertebra equipped with a tracker forms a region of interest and a bounding box is drawn around each of said vertebrae.
  • the bounding box is an advantageous tool for initializing the registration.
  • the shape of the bounding box is as close as possible to the shape of the region of interest, in order to improve the convergence and increase the accuracy and reliability of the registration.
  • the bounding box may be drawn manually by the user. Alternatively, the bounding box may be automatically drawn by the computer, and may be interactively adjusted by the user. However, such a bounding box does not involve any segmentation of the bone.
  • each region of interest defined by a respective bounding box is registered with the corresponding region of the preoperative 2D X-ray image(s).
  • step 403 an integrated 3D image is computed from the registered regions.
  • step 500 The planning of step 500 is then made on the integrated 3D image computed in step 403.
  • the registration and the planning may thus not be carried out on the whole set of bones, but only locally in the determined regions of interest.
  • One application of the invention may be hip surgery, e.g. total hip arthroplasty, which is intended to implant an acetabular cup into the pelvis and a femoral prosthesis into the femur.
  • At least one preoperative 2D X-ray image of the hip joint is received.
  • FIG. 6 schematically represents preoperative 2D X-ray images of a patient's hip joint in frontal (left) and lateral (right) views.
  • the patient is equipped with two bone trackers 3f, 3p, one rigidly connected to the femur and another one rigidly connected to the pelvis.
  • Those trackers are represented in FIG. 5 in a symbolic manner for better understanding of the following method but they are not present during the acquisition of the pre-operative images.
  • the 3D image acquired intraoperatively is usually smaller than the preoperative 2D X-ray image but it must include at least the femoral head and the acetabulum.
  • the registration of the intraoperative 3D image and the preoperative 2D X-ray image may be made as follows.
  • a bounding box BBF is drawn around the femoral head in the preoperative 2D X-ray image.
  • Another bounding box BBp is drawn around the acetabulum in said preoperative 2D X-ray image.
  • each bounding box may have a different shape.
  • each bounding box may preferably have a shape that fits closely the shape of the region of interest of the corresponding bone. From a few landmarks such as a circle defining the hip sphere and a rough orientation of the acetabulum, it is possible to define automatically well adjusted bounding boxes.
  • Both regions of interest defined by a respective bounding box in the preoperative 2D X-ray image is registered with the corresponding region of the intraoperative 3D image.
  • the system thus computes a 3D integrated image from the registered regions.
  • the user may thus plan the position of the prosthetic components on said integrated 3D image. More precisely, the planning provides an optimal position of the acetabular cup relative to the tracker attached to the pelvis, and an optimal position of the femoral prosthesis relative to the tracker attached to the femur.
  • FIG. 7 schematically represents a part of a patient's spine along with a 2D pre-operative image of the patient's spine.
  • a bone tracker for the surgical intervention.
  • Only a few vertebrae may be equipped by a tracker 3v1, 3v2, 3V3 attached to a respective vertebra using an attachment device 50 clamped on the vertebra.
  • Patient trackers are represented in FIG. 7 in a symbolic manner for better understanding of the following method but they are not present during the acquisition of the pre-operative images.
  • the preoperative 2D X-ray image is sufficiently large to encompass the whole spine SP. Thus, all the vertebrae intended to be equipped with a bone tracker are visible in the preoperative 2D X-ray image.
  • the 3D image acquired intraoperatively is usually smaller than the preoperative 2D X-ray image and generally does not encompass the whole spine. Instead, a 3D preoperative image may be acquired for each vertebra equipped with a bone tracker, or for a set of such vertebrae.
  • the registration of the intraoperative 3D images and the preoperative 2D X-ray image may be made as follows.
  • a bounding box BBv1, BBv2, BBv3 is drawn in the preoperative 2D X-ray image around each vertebra equipped with a bone tracker.
  • each bounding box may have a different shape.
  • each bounding box may preferably have a shape that fits closely the shape of the vertebra.
  • Each region of interest defined by a respective bounding box in the preoperative 2D X-ray image is registered with the corresponding intraoperative 3D image or region of the intraoperative 3D image.
  • the bounding boxes allow efficiently initializing the registration by providing a correspondence between the vertebrae in the 2D and 3D images.
  • the system thus computes a 3D integrated image from the registered regions.
  • the user may thus plan an optimal position of a surgical correction on said integrated 3D image, including also screw and rods positions.
  • the planning may define a position of a tracker attached to a vertebra relative to at least one tracker attached to another vertebra.
  • a bone tracker may be considered as a surgical instrument to be optimally positioned with respect to another bone tracker.
  • the invention is not limited to the above applications but may be used for any surgical intervention involving at least one bone, preferably when it is desired to take into account a position of interest of the patient when planning the intervention.
  • the position of interest is the standing position of the patient. In another preferred embodiment, the position of interest is the sitting position of the patient. In the case of shoulder surgery, the position of interest may be the extreme motion of the humerus with respect to the scapula, before surgery.
  • the intraoperative 3D images obtained during surgery can be registered with post-operative 2D X-ray images.
  • This method offers a complete chain to compare surgical planning performed on standing 2D X-ray images and post-operative results obtained on other standing 2D X-ray images. This method can be applied for other positions of interest.

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EP19306464.9A 2019-11-12 2019-11-12 Verfahren und system zur bestimmung einer optimalen position eines chirurgischen instruments in bezug auf einen knochenverfolger eines patienten Pending EP3821844A1 (de)

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JP2023036040A (ja) * 2021-09-01 2023-03-13 オーソソフト アンリミティド ライアビリティ コーポレイション 蛍光透視鏡ロボット人工埋植システム及び方法
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EP4169473A1 (de) * 2021-10-25 2023-04-26 Erbe Vision GmbH Vorrichtung und verfahren zur registrierung von livebildern und scanbildern
EP4173590A1 (de) * 2021-10-26 2023-05-03 Ecential Robotics Verfahren zur registrierung eines medizinischen 3d-bildes mit einem registrierungsphantom
WO2023072887A1 (en) * 2021-10-26 2023-05-04 Ecential Robotics Method for registering a 3d medical image with a registration phantom

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